Client sign in sheet 2 .doc
DOC document 39 KB Posted
- Attached to
- Reception Intake Sheets for Skowhegan OFI
- Solicitation number
- RFQ - 10A - 12112800000000000490
- Issued by
- Sagadahoc County, Maine
About this file
This document is a client sign-in sheet for the State of Maine's Office of Family Independence (OFI) intake process at the Skowhegan location. The form serves as an intake document designed to collect client information while protecting confidentiality. The sheet captures basic client data including name, date of birth, and case name, and identifies current benefit receipt status across three primary assistance programs: Food Supplement Benefits, MaineCare, and Temporary Assistance for Needy Families (TANF). The form accommodates multiple purposes for client visits, including new applications or re-applications for benefits, emergency assistance requests, case reviews, information updates, status inquiries, and case modifications such as adding household members.
The intake sheet provides checkboxes for clients to indicate the reason for their visit and tracks appointment information for two distinct service tracks: ASPIRE and Child & Family services. The document is formatted as a duplicate form allowing for multiple client intakes to be recorded on a single page. No specific pricing terms, contract amounts, funding sources, or award dates are indicated in this document, as it functions primarily as an administrative tool for client services intake and information collection rather than as a procurement or contract specification document.
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Text version
INTAKE # __________
INTAKE # __________
TO PROTECT YOUR CONFIDENTIALITY WE ASK THAT YOU COMPLETE THE INFORMATION BELOW
Your Name (Please PRINT): ________________________________________ Date of Birth: _____________ Case Name (If different from above): __________________________________________________________ I am currently receiving:
FORMCHECKBOX
Food Supplement Benefits
FORMCHECKBOX
MaineCare
FORMCHECKBOX
TANF
Purpose of your visit today (Check all that apply):
I would like to apply/re-apply for:
FORMCHECKBOX
Food Supplement Benefits FORMCHECKBOX MaineCare FORMCHECKBOX
TANF FORMCHECKBOX
Emergency Assistance
FORMCHECKBOX
I need to complete a review. FORMCHECKBOX Has FORMCHECKBOX Needs FORMCHECKBOX Sent In
FORMCHECKBOX
I have information. FORMCHECKBOX I have questions.
FORMCHECKBOX
I need to report changes. FORMCHECKBOX I am adding a member to my case.
FORMCHECKBOX
Other (please explain): __________________________________________________________________
FORMCHECKBOX
ASPIRE / Appointment time ____________ FORMCHECKBOX Child & Family _____________________________
INTAKE # __________
INTAKE # __________
TO PROTECT YOUR CONFIDENTIALITY WE ASK THAT YOU COMPLETE THE INFORMATION BELOW
Your Name (Please PRINT): ________________________________________ Date of Birth: _____________
Case Name (If different from above): __________________________________________________________
I am currently receiving:
FORMCHECKBOX
Food Supplement Benefits
FORMCHECKBOX
MaineCare
FORMCHECKBOX
TANF
Purpose of your visit today (Check all that apply):
I would like to apply/re-apply for:
FORMCHECKBOX
Food Supplement Benefits FORMCHECKBOX MaineCare FORMCHECKBOX
TANF FORMCHECKBOX
Emergency Assistance
FORMCHECKBOX
I need to complete a review. FORMCHECKBOX Has FORMCHECKBOX Needs FORMCHECKBOX Sent In
FORMCHECKBOX
I have information. FORMCHECKBOX I have questions.
FORMCHECKBOX
I need to report changes. FORMCHECKBOX I am adding a member to my case.
FORMCHECKBOX
Other (please explain): __________________________________________________________________
FORMCHECKBOX
ASPIRE / Appointment time ____________ FORMCHECKBOX Child & Family ___________________________
File details come from the government source that posted it. Updated .